Pediatric Coding Alert

Question: Our insurance company bundles an office visit with the code for PPD administration and paying one or the other, but not both. Should we file something differently?

North Carolina Subscriber

Answer: Ensure you’re reporting the correct codes for the office and PPD codes, and that you have documentation for the medical necessity of the office visit along with the PPD administration. Begin with the appropriate E/M code, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for a documented E/M nurse visit. Report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or above if the PPD test is part of a more extensive physician visit with other services.

Then add administration code 86580 (Skin test; tuberculosis, intradermal). Link diagnosis V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis) to 86580.

Tip: CPT® does not require that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional of the same day of the procedure or other service) to the E/M code. However, some insurance companies require the modifier, so check your local guidelines if you are having problems with payment.